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Questions and Answers
CPR will be instituted if the client goes into cardiopulmonary arrest.
True
Which factors may increase the client's risk for falls? (Select all that apply)
What actions should the nurse take regarding a confused client after hip arthroplasty? (Select all that apply)
Which action indicates a need for further education for the newly licensed nurse using a drawsheet?
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What is the first action the nurse should take for a client with a low blood glucose reading?
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Number the following actions in the appropriate sequence after a medication error:
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Which statements about incident reports should the nurse manager include? (Select all that apply)
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What should be done with the client's belongings before surgery?
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What must the nurse ensure about client medical records?
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What is the appropriate action after caring for a client who has been exposed to anthrax?
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An RN has to teach the client initially but can delegate ________ to an LPN.
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An LPN can perform ______ care.
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Can an RN delegate to an LPN to perform suctioning?
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Can an RN delegate to an LPN to put in a urinary catheter?
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Can an RN delegate to an AP to feed a client not on swallow precautions?
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Is an RN allowed to delegate to an AP to collect a urine sample?
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A nurse delegates to an AP to assist in obtaining vital signs from a postop patient who required naloxone (narcan) for depressed respirations. Is this an appropriate task for the AP?
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An older adult client who is on fall precautions is found lying on the floor of his hospital room. Which of the following actions is most appropriate for the nurse to take first?
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Which of the following tasks should the nurse delegate to the LPN?
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Which of the following is an appropriate response by the nurse regarding a medication for a client who is not present?
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Which of the following describes a case management approach to care?
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What action should the nurse take after overhearing a client reporting physical abuse?
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Which of the following situations should be included in a discussion about client advocacy?
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Which of the following is a likely reason for negligible progress in a weight loss program?
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Which of the following is an appropriate action by the LPN when asked to give an injection?
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What should be the initial method to resolve tension among nursing staff?
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In which order should the nurse take action when a client receives a medication not prescribed?
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Which of the following tasks should the nurse delegate to the assistive personnel (AP)?
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Which client should the nurse assess first?
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Which task should the RN assign to the LPN?
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Which of the following is a requirement for governing controlled substances?
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Which of the following options is appropriate for the nurse to discuss with the family of a client with early Alzheimer's?
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Which of the following approaches reflects an assertive response to conflict resolution?
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Which priority finding should the nurse report to the provider?
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Which is the priority assessment finding for a client recently prescribed lithium carbonate?
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What does the 'Code of Ethics for Nurses with Interpretive Statements' serve as?
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Which priority action should a nurse manager take concerning health-care associated infections?
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What should be considered when planning a performance appraisal for a newly graduated nurse?
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Which multidisciplinary members should contribute to the plan of care for a client who has had a left hemispheric stroke?
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Which decision-making style is being demonstrated by a nurse manager who collects data for policy updates?
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Which actions support interprofessional collaboration?
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What action should the nurse take regarding a client's advance directive information?
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Which situations illustrate the advocacy role of a nurse?
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Which document outlines the rights of individuals in health care settings?
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A nurse discovers that the client's DNR order has expired. The client's condition is not stable. The nurse should ___ ___ ___ .
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Study Notes
Delegation and Task Management
- RNs can teach clients but may delegate reinforcement of teaching to LPNs.
- LPNs are authorized to perform specific care tasks like tracheostomy care and suctioning.
- RNs can delegate feeding clients not on swallow precautions to APs and also the collection of urine samples.
- Delegation to assistive personnel (AP) for vital sign checks on post-op patients requiring naloxone is inappropriate due to the need for careful assessment.
Client Care Scenarios
- If an older adult on fall precautions is found on the floor, priority is to inspect for injuries before any other action.
- After surgery, RNs can assign LPNs to take vital signs of post-op clients but not to administer blood or develop care plans.
- RNs are responsible for communicating medication information to clients and families, upholding confidentiality and compliance with health policies.
Advocacy and Ethical Responsibilities
- In cases of suspected abuse, nurses must report allegations to management for investigation.
- Client advocacy includes clarifying and discussing treatment options, assisting with questions for the provider, and ensuring care aligns with living wills.
- Ethical guidelines for nurses, such as the Code of Ethics, are not legally binding but serve as a professional guide.
Quality Improvement and Performance Management
- The audit process involves structure evaluations, outcome assessments, and addressing sentinel events via root cause analyses.
- Performance appraisals for staff should include comparisons to standards and allow self-evaluation opportunities.
- High rates of healthcare-associated infections (HAIs) should prompt immediate reviews of hand hygiene practices.
Patient Safety and Risk Management
- Advance directives are essential, and patients need guidance on their importance, even if they initially express disinterest.
- In home assessments, factors increasing fall risks include vision impairment, previous fall history, and living conditions such as wearing slippers.
- For clients post-surgery experiencing confusion and risk of dislocating joints, restraint application requires provider orders and family consent.
Interprofessional Collaboration and Care Planning
- Effective interprofessional teams include members like occupational and physical therapists, psychologists, and vocational counselors, especially for rehabilitation clients.
- During patient transfer reports, key information includes advance directive status and special equipment needs but not the type of anesthesia used.
Managing Conflicts and Team Dynamics
- Addressing team tensions should start with identifying stressors collaboratively.
- Adaptation of decision-making styles in nursing management can support team engagement and collective problem-solving.
Core Nursing Responsibilities
- Delegation should prioritize tasks appropriate to skill levels, with RNs managing medications and LPNs handling specific procedures.
- Priority patient assessments focus on those with the highest risk factors, ensuring timely interventions.
- Documentation of procedures and medication administration ensures accountability and quality in care delivery.### Nursing Actions for Medication Error
- In the event of administering an antihypertensive medication in error, begin by monitoring the client's vital signs to assess any immediate effects.
- Instruct the client to remain in bed until a provider can evaluate the situation.
- Contact the client’s provider to inform them of the error and receive further instructions.
- Complete an incident report that outlines the error and the actions taken in response.
- Notify the risk management department to ensure that the incident is documented and reviewed for quality improvement.
Incident Reports in Nursing
- Documenting a description of incidents in the client's healthcare record should not include sharing incident reports with the client.
- Incident reports must encompass a detailed account of both the incident and the actions that followed.
- The risk management department is responsible for investigating the incidents to ensure patient safety and compliance.
Patient Assignment for New Registered Nurses (RNs)
- New RNs should only be assigned patients with whom they are competent, and this competency must be verified by an experienced RN before patient assignment.
Tracheostomy Discharge Planning
- Always keep two extra tracheostomy tubes available: one that matches the client's size and one that is a size smaller.
- Ensure that an obturator and trach ties accompany each tube, along with sterile saline and lubricant for emergency care.
Confidentiality in Nursing Practice
- Client medical records must be stored securely, with access limited to authorized personnel only.
- Information cannot be shared with unauthorized individuals unless they provide a specific code for verification.
Preoperative Nursing Care Protocol
- Instruct family members to safeguard the client's belongings by storing them safely before any procedure.
Client Care Prioritization
- Apply the prioritization hierarchy: systemic issues before local ones, acute situations before chronic conditions, and actual problems before potential ones.
- Recognize trends in client health rather than assume findings; identify emergencies and complications through careful assessment.
Ethical Principles in Nursing
- Adhere to ethical responsibilities including justice (fairness), beneficence (acting in patient’s best interest), nonmaleficence (doing no harm), fidelity (keeping promises), autonomy (respecting independence), and veracity (truthfulness).
Emergency Informed Consent
- Informed consent can be bypassed in emergency situations where a client is unconscious and surgery is critical for survival.
Telephone Prescription Protocol
- When receiving a telephone prescription, it is important to write the details down correctly, repeat the prescription back for verification, and document the conversation in the client’s chart.
Tort in Nursing Practice
- A tort is defined as a wrongful act or infringement of a right that causes harm or loss to another, leading to legal liability.
Performance Improvement in Client Care
- Quality improvement processes are established through policies and procedures, identifying issues via staff feedback, and analyzing current practices to improve outcomes.
Home Safety Assessment for Clients
- Conduct a thorough home safety assessment by removing tripping hazards, securing electrical cords, ensuring that steps are well-maintained, installing grab bars, utilizing non-skid mats in wet areas, and ensuring adequate lighting throughout the home.
Healing Assessment for Wounds
- Inflammation in wounds indicates that the body's immune system is actively engaged in the healing process.
Variance Reports for Financial Comparison
- Variance reports serve to compare projected budgets with actual financial outcomes, aiding in financial oversight and management.
Protocol for Anthrax Exposure
- Clients exposed to anthrax should receive prompt antibiotic treatment to prevent disease development.
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Description
Test your knowledge on leadership delegation within nursing with these flashcards. This quiz covers roles and responsibilities for RNs and LPNs, specifically addressing tasks such as teaching, care procedures, and delegation policies. Perfect for nursing students preparing for their ATI proctored exams.
